Paramedic Blog

In my early years few departments used bags, everything was in some kind of hard box. But the boxes were all heavy and hard to carry. I can remember one ambulance company that manufactured a wheeled cart to carry them and the monster defibrillator of that era. So in the early 80’s EMS providers started switching over to soft cases. The first of these were pretty cheaply constructed, but then along came Thomas Packs and Pacific Packs. People began to appreciate the ease of use and those wonderful shoulder straps. It wasn’t long before most EMS agencies were using soft cases. A good bag, properly engineered to the mission, can help you deliver better care more quickly. But a poorly designed bag can slow you down and create enormous frustration. Here are a few important considerations when selecting a new Trauma Bag or Medical Kit. 

Context: You must examine each new bag purchase in the context of how everything else is carried. The idea is to balance loads so that “no hand carries more than another”. If you can more equally balance what gets carried in more evenly you will have a lot less fatigue and I believe reduced injuries. This is not always possible; often one item will outweigh the rest. 

Examples are when you are forced to carry steel E tanks, or perhaps a full-featured 12-lead defibrillator will outweigh the other components. But don’t make this situation worse. Some agencies insist on trying to combine everything in one huge bag. 

Try Them On: Buying a bag in a picture book or the internet for the first time is like getting a mail order wife. I highly recommend you get a sample and put your equipment in the bag. Stock it just as you plan to use it, and see how everything lays out. Then think about how you use these items. I’ve found what works best is to look at two specific but very different considerations. 

1. Are the things you use the most often easily accessible?
2. Are the things you want instantly when you do need them (like an OPA) only one zipper-pull away? 

A portable oxygen tank is something you use on almost every call. So it needs to be immediately accessible. The oxygen supplies for it need to be right next to it. If you had to open yet another zipper to get the mask out for it, it would really slow you down. 

Look at the Details: Look carefully at the side and corner seams for signs of irregularity or puckering. A bag that isn’t cut right won’t go together right. 

• Look at the handle attachments and shoulder strap mounts. Will they hold up to the weight you plan to load in it? 
• Look at the inside of the bag where the main zipper attaches. Is it single or double stitched, and how straight do the sew lines run? This is one spot on most bags where shoddy construction will be revealed most easily, particularly around the corners. 
• Check the impact liner. Is it cheap open cell foam they goes “pop” between your fingers and soon stops providing protection? Or is it high-density foam that will take years of abuse? 
• Is the bottom double-layered or reinforced in some manner? This is a primary wear point on many kits. It should also be constructed to resist fluid penetration. 

Don’t Put a Pig in a Thimble: I’ve long suspected that the Hepatitis B vaccine is strangely contaminated. I have no other explanation for the apparent pathogen. It seems like all EMS people and only EMS people; will always try to put 15% more stuff in the bag than it was designed to hold. It must be a virus. I’ve seen oxygen bags with 15 oxygen masks. This is ridiculous but I think I know why some do it. It’s because they don’t want to restock promptly after each call. 

I worked at a station once, where whenever I was gone for a few days the bag would inexplicably grow. So did the weight and also my frustration level when later on that shift I was trying to find something. If you overstuff your kits you make them harder to use and they also wear out sooner. Periodically go through your kits to look for items you never use. If you have not used it once in years, maybe it can stay on the truck.

Get Everyone Onboard: This is one purchase that you would be well advised to seek consensus on. EMS providers are deeply affected by changes in deployment systems. I suggest you leave the stocked “new” bag in the kitchen or somewhere for a few days. Give everybody a chance to see his or her stuff in the bag before you buy. 

My last great clinical save was a narcotic OD. It was good quality ventilation that gave this kid another chance. Using a BVM is one of the most difficult skills to master. It’s impossible with a BVM to accurately titrate therapy to clinical requirement. We often don’t even realize how fast we are going. They are notorious for delivering high inspiratory pressures and dangerously low tidal volumes.

Controlled Ventilation is when all aspects of respiratory resuscitation are medically managed by the clinician. It requires delivery of a respiratory gas dose administered to the specific size, age, weight, and condition of the patient.

These are just a few of the many good reasons to consider purchasing a ventilator. Oxygen is the most important drug we give, but only with a ventilator can you be in complete control of the dose. Buying the right kind and best model for your particular application is critical. There are five basic types;

Resuscitators: Resuscitators offer basic ventilation support during CPR and Respiratory Arrest. Most are fully pneumatic and oxygen powered. They provide controlled ventilation in emergency situations. They are primary intended for use with a face mask or rescue airway. They grant the rescuer effective control over tidal volume and respiratory rate, delivered at controlled inspiratory pressures. Examples included;

• The Smiths Medical PM Inc. VR1
• The Impact Instrumentation Inc. Uni-Vent® 706
• The AutoMedxSAVe  
• The O-TWO Systems CAREvent® Handheld Resuscitators  
  

EMS Ventilators: EMS/Transport Ventilators offer time-cycled, volume constant operation. They are built for the rigors of pre-hospital care. They are typically fast to deploy and easy to use. They use intuitive Tidal Volume and Rate controls. They can accommodate the basic needs of ventilator dependent transport patients and are suitable for emergency ventilation. Some now also include a CPAP function which expands versatility. Examples include;

• The Allied Healthcare AutoVent 4000
• The Smiths Medical Pneupac® paraPAC
• The O-TWO Systems CAREvent®
• The Aieron pNeuton Ventilator
  

Critical Care Transport Ventilators: Critical Care/Transport Ventilators are designed to duplicate the advanced functions of acute care ventilators. Most can deliver CPAP and/or BiPAP, and are suitable for EMS and ICU patients during transportation between hospitals. The big difference between CCT Ventilators and Hospital Transport Ventilator is CCT units are intended for use in mobile medical transport applications. Many are certified for aeromedical use, and most have included EMS application specifically in their FDA 510K submission. Examples include;

• The Draeger Medical Oxylog 3000
• The Impact Instrumentation Model 754 Uni-Vent® Eagle™
• The Smiths Medical Pneupac® ventiPAC
  

Hospital Transport Ventilators: Hospital Transport Ventilators are mainly designed for patient transportation inside the hospital. They are suitable for ICU/Critical Care patients and for specialized applications outside the hospital.

• The BMD Bio-Med Devices Crossvent 3+
• The VIASYS Healthcare - Pulmonetic Systems LTV 1200 Ventilator
• The Newport Medical Instruments Inc. Newport e360
  

Disaster Ventilators: Disaster Ventilators are mainly used for Mass Casualty applications. They are generally inexpensive and compactly stored. They are intended for long-term disaster caches and/or surge capacity. They also have applications in the military theater. Some offer a built-in compressor and others are battery or gas powered. They can replace hospital ventilators after compressed oxygen has run out or during a long power outage. Examples include;

• The Hartwell Medical SureVent Disposable
• The Allied Healthcare EPV100 & MCV100
• The Impact Instrumentation Model 73X
  

The most important consideration in purchasing a ventilator is how you intend to use it. If the purchase is to gain the capability to do intra-facility critical care transports then pick a model with the advanced features you need. You will probably need to be able to mimic most hospital settings and functions. If you primarily do street EMS you need something rugged, compact and fast. If you are BLS, you want something simple like one of the Resuscitators.

Consider that a new ventilator purchase is an opportunity to expand capabilities. If you need a transport ventilator – talk about the benefits of upgrading your emergency ventilation capability. If you need a good EMS ventilator, discuss the possibility of including CPAP with your purchase. In today’s economy it’s good practice to get the very most you can for your money. In the case of a good ventilator, that’s often includes the potential for an expanded scope of practice.

Invest in good training. The best equipment in the world is of little benefit in untrained hands. I often see departments buy things that cost thousands of dollars and fail to perform decent staff training. If you don’t have either the will or the capability to demand rigorous training on a sophisticated medical device - then keep it very simple. A good simple Resuscitator can still improve the quality and consistency of ventilation while being highly intuitive to operate.

Ventilators have been around since the 1930’s. This is a mature and well-developed technology. Many EMS agencies have enjoyed important benefits by taking control over the administration of the most important drug they give in the field. Some of these benefits are improvements in the quality of care, redistributed staff time, controlled operating costs, and expanded capabilities. But the very best benefit is the opportunity for a conversation afterwords. With someone you treated for respiratory or cardiac arrest. Those rare but rewarding moments are what keep me excited about EMS. For more information see Jim Hoffman's excellent article.

Modern concepts and methods of Triage and Mass Casualty Management have evolved a lot in recent years. What was once the simple act of patient sorting is today a refined science. Recent domestic events like Oklahoma City, 911, New Orleans, and the H1N1 scare have focused our efforts to develop improvements in disaster preparation and mass casualty management.

Most of my experience with large-scale events was gained long before these ideas got mainstream. I’ve been to several large fires and building collapse events, one large flood, a building explosion and enumerable multi-vehicle wrecks. Most were managed pretty poorly on retrospect, but the experience taught me a lot. Here’s what I learned.

We first have to set up a minimal command structure or organize. Then we sort the injured with the goal of moving the worst hurt viable first. We have to keep track of who goes where, and manage how many go to any one hospital. Last, we have to match the patient to the best destination to optimize their outcome. We have to get the right people to the right place in the right order.

As an EMS Provider your primary job is to do two things; Identify who is the most injured and get the most viable of the injured transported first. If you are not very good at that yet, then that is where your initial efforts should be focused. Alaska published a great over-view of the basics. An important concept is the idea of using your MCI tools on micro-incidents. An example of a micro-incident is a nasty 3-car accident with 4 victims. If you practice your MCI techniques on these smaller incidents, you will be much better prepared for a large disaster. Being able to set up a command structure fast with the first four responders is a mission-critical skill.

I’ve found that MCI’s tend to be won or lost in the first few minutes. The last thing you want is things spiraling out of control while you are stuck waiting for an MCI trailer to arrive. Smaller scale implementation of MCI management gets you used to using your triage tags, forms, and other tools. You will find out quickly if the vests fit, if the collection area markers can be seen at night, and many more things than you can imagine. Then when a true system challenge occurs you have already worked the bugs out of your system.

Mock events are an invaluable tool for MCI preparation. But use scenarios based on practical assumptions of what is most likely to occur or with the greatest historical relevance. Remember that if it happened once, it can happen again. Massachusetts published a wonderful MCI planning guide. A natural tendency is to prepare for what most recently happened somewhere else. After New Orleans people got real about flood preparation. After the Minnesota bridge collapse, every bridge in Missouri got inspected immediately. Today the hot topic is pandemic flu preparation. Tomorrow it will be big train wrecks.

The one aspect of MCI management rarely discussed is the emotional demands. It seems we plan for recovery afterward with Critical Incident Management (CISM) programs, but don’t talk much about the challenge beforehand. What I’m talking about is being emotionally prepared for how different your role will be at an MCI. One of the hardest things I’ve ever had to do as a Paramedic was walk past a women begging for my help, because someone else beyond her needed me more. I think we need to have some frank discussions about these feelings before we have to deal with them.

MCI Planning and Preparation is a young science, founded on the battlefields but carried out today largely in the boardroom. How well we plan and prepare will eventually be tested in every system. It may not be today, this month, or even this decade. But it’s far better to plan under the assumption that every single one of us will eventually need these important skills and is completely prepared to execute.

This completely modern and revolutionary new ambulance design will change the face of EMS in America. It has all the latest safety and performance innovations American ingenuity can muster. It’s sleek, fast, safe and sexy. I think this ambulance could be the transportation technology breakthrough we’ve been waiting for.  It’s clearly a whole new way to practice EMS on the street.

My first amazement came when I opened the aerodynamic hood, to see the 500 cubic inch monster gas engine under the bonnet. The air intake was suitably massive to feed the thing plenty of air. Modern electronics were in prominent display everywhere. As I moved to the driver’s seat the interior luxury abounded. I sunk into deeply cushioned seats richly covered in leather, with power adjustments in every seating position. It even had a lavish detailed and padded armrest to complete the package.

Moving to the rear compartment, the placement of everything just made sense. The attendant’s seat was forward facing and at arms reach of the patient. No more dancing like a circus bear while rendering critical care. The Paramedic has every single instrument and control system within easy arms reach. Heaven forbid you get in an accident; the folding safety seat and restraint system will keep you right where you belong. From the way everything is constructed and the 7,000 lb weight, I imagine anything you hit in it will be the looser. I got a brief ride in the back and was even more impressed.

The adjustable air-ride suspension system dampened out the rough spots on the road. The use of sound insulating panels made the interior as silent as a church.  It was so quiet and rode so smooth I could hear the heartbeat and watch a crystal-clear ECG tracing on the screen. Even a BP was easier to take because I could actually hear it. This vehicle has the best acoustic insulation and ride dampening system I’ve ever experienced. Even loading it is a breeze with an entry height lower than anything else on the street. The interior conveniences continued to impress.

Air conditioner and heater vent abounded, I counted at least 6 to keep my patient and me comfortable. Copious windows completely surround the patient compartment. Combined with the powerful ceiling lights they made for much better visibility. All my critical equipment is securely wall or bulkhead mounted, yet immediately available. Privacy drapes insure modesty during examinations and the second head-end seat makes for convenient access to the airway. Then they let me drive it and I fell in love.

The astonishingly low center of gravity combined with the ultra-light composite top made for sports car-like handling. Lane changes and evasive maneuvers were easy. The handling is solid and predictable, without compromise to the dreamy ride in the back. I can see how a good wheel man could get me to the ER without me ever feeling a thing in the back. There’s just one huge problem with this ambulance. It’s a 1978 Superior Cadillac and you can’t buy it anymore.

Today is a great day to think about preparing for a flu epidemic. Will you reply on standard oxygen masks, and then sit right next to what comes out of the exhaust vent? Or will you put an N-95 respirator on the patient while their hypoxia worsens? If you don’t like these choices take a look at the FLO2 Mask from BLS Systems. The FLO2 Mask is a new product for delivering high-concentrations of oxygen while filtering the patients exhaled air. It’s an important breakthrough in infection control and pandemic planning. In Canada many have already stockpiled them, but in the USA few EMS departments or government agencies are aware of the product yet.

What really happens when you put a standard non-rebreathing oxygen mask on a patient with a respiratory infection? Answer: You ride to the hospital in a cloud of their exhaled contaminants.

Researchers in Canada believe this may be the mechanism by which so many acquired SARS in Toronto Hospitals.

The Solution is the FLO2 Max.

The FLO2 Max is a low flow, high concentration oxygen mask combined with a hydrophobic submicron filter. It delivers concentrations of 30%-99% oxygen. It is compatible with most nebulizers. All patient exhalation is filtered through a 3M-brand submicron filter. It protects Paramedics, other Patients, and Healthcare Workers with over 99.9% bacterial and viral filter efficiency. Should oxygen flow cease the valves will allow the patient to breath normally on room air. This product is an important tool for managing respiratory borne infections. It allows the pre-hospital clinician to deliver oxygen therapy while protecting themselves and other staff.

Two weeks ago nobody cared much when I talked about the importance of this unique new product. This week I think more EMS providers will be eager to hear about it. It’s a great way to protect your staff while transporting patients with respiratory illness in a pandemic situation.

The big new trend at EMS Today this year was the rapid growth of new optical and video intubation devices. It’s particularly incongruous that in a month when the big feature article in JEMS is about “The Vanishing ET Tube”, our industry introduces several new tools that make intubation easier and possibly safer.

Larger versions of these devices have been in most anesthesiologists’ arsenal for years. They allow the clinician to view the intubation procedure on a remote screen. Often these devices can provide a much broader field of view in high definition color. Manufacturers continue to make them smaller and more rugged with some models engineered specifically for EMS use. I saw several brand-new intubation devices at EMS Today. Some I had never even heard of previously. Every single one was of very high-quality construction. Many hold the promise to make quickly securing a definitive advanced airway easier, safer, and faster.

The first two that caught my attention came from Clarus Medical. One features a compact screen on the handle. It blends the benefits of an optical stylet with video technology. It can display or export the video signal with a convenient USB port. The second was the new Levitan FPS Scope. This device is a malleable fiber optical stylet with a small view port and oxygen insufflation port. This provides assistance to those learning how to use the device by exploiting that little-credited teacher’s helper, body memory.

Body memory is what allows you to ride a bicycle even if you have not done so for decades -- your body remembers how, but it needs plenty of repetition to acquire the memory. Developing that body memory is what becomes mission-critical with each new trick in your bag. How many tricks will you try to learn to do well and what other skill could that effort degrade. These are the issues that can complicate and reduce the net value of acquiring new skills. That’s what I like about the Levitan Scope: it’s the same old laryngoscopy technique I’ve always used before, just with an added twist at the end.

You hold the Levitan in your right hand with your ET tube loaded on it, and a laryngoscope in your left hand just like you are used to. Once you see the tip approach the glottis, you transition from looking in the mouth to looking through the eye port to pass the tube under direct visualization. You can follow the tube all the way in and watch as it passes through the chords. If for any reason the view becomes obscured, as what might occur with blood or vomitus in the airway, you still have a great fallback position.

Next you turn on the special LED at the stylets tip and use it just like a light wand for trans-illuminated tracheal intubation. Frankly I could see just using it as a stylet on easy tubes. After all, as you approach the glottis, if you can see it easily enough, you’ll probably stick it in. Personally, I’d like to play with the idea of turning on the trans-illuminating LED light as I begin to insert the tube - for routine external visual confirmation of placement as I pass the glottis. I see the potential for this one device, the Levitan, to provide an escalating level of response to each individual airway challenge. It’s also one of the most compact and economical of the new intubation devices I saw at the show

A sexy new video laryngoscope on display was the C-MAC Video Laryngoscope from Karl Storz. This versatile system operates in a similar manner to the Ranger Glidescope. It has a laryngoscope component and a separate view screen system. The quality was simply stunning, with the robust laryngoscope component exhibiting the finish and feel of an expensive handgun. This stuff is so nice I was a little nervous to ask how much it cost. But for best in class, these systems have to be on your short list.

The public did not get a chance to see the new Coopdech C-Scope, but we received a private showing. This video laryngoscope has a traditional look, with a screen that while not as vividly clear as the Pentax, was noticeably larger and located right on the handle. The handle itself provides a more traditional laryngoscope feel, and uses replaceable blades that will come in a variety of sizes and style.

The next new advancement in intubation looked like a regular laryngoscope with two lights. But it is far more than it initially appears. The IntuBrite has a second Ultraviolet light, which causes the vocal chords to stand out like you have never seen them before. The blades themselves are completely disposable. The handle is also very innovative -- it has a much more ergonomic design which enhances operator control. The curved shape helps you direct the lifting force to its greatest advantage.

We can always strive to do a better job of managing the emergency airway. New technologies such as those we saw at EMS Today may prove to have a vital role. Some of these new devices are expensive but compared to the cost of a new LED light bar; the price justifies itself considering the potential benefit. We can -- and should -- be masters of a full range of critical life-saving skills that reflect the best standards of care and advancements in technology.

One new airway toy at EMS Today was not a laryngoscope at all. It’s a new bougie from SunMed. This new malleable introducer is a big improvement on what is a great second-line airway technique. The original introducer or bougie was also often called a gum elastic bougie. These simple “sticks”, are just more than twice the length of an ET tube. You can put them in first when passing a tube proves initially difficult, and then just slide the tube in over the top of them. It’s a really great technique for those tough intubations when you can see the epiglottis but can’t get a decent angle for passing the tube under it. 

I’ve found trying to put the tube on while you hold the bougie in place a sort of three-handed thing. So I like to pre-load the tube onto the bougie with enough sticking out to provide that narrow yet firm advantage. The new SunMed Malleable Introducer or bougie, is the first one of it’s kind built to use exactly that way. It provides firm directional control with a stopper to hold the tube in place, right where it should be.

You first pre-load your ET tube onto the introducer where it stays firmly secured by the movable tube stop. Leave about 3 or 4 inches of bougie protruding out the end of your ET tube, and then form it to your preferred shape. Once you get the end of the introducer bounced up under the epiglottis, you slide your tube into the trachea using the introducer as a guide wire. This cool airway trick is so inexpensive, that everybody should have one in his or her kit.

For more check out my earlier post on the subject,or the

Training Video from Airway911

There are currently four different ways to deliver CPAP in the field:

1. The Downs Flow Generator - The Downs Flow Generator is the original CPAP machine. There are currently two distinct types of Downs Flow device, the Adjustable Flow and the Fixed Flow. They are simple and rugged devices featuring a DISS input, round or square shaped expansion chamber, venturi air entrainment port, and circuit connection. 

The expiratory phase is controlled separately at the patient mask with a PEEP valve. The non-adjustable type PEEP valves work better than adjustable PEEP valves, but make it less convenient and more expensive to adjust pressure. The latest version of the Adjustable Downs Flow type CPAP is the new FloPAPP from Flotec, Inc. The FloPAPP features adjustable aspiratory flow rates and an adjustable PEEP valve on the mask. This allows the clinician to slowly increase PEEP pressure to protocol-based pressure objective or patient tolerance. With adjustable inspiratory flows, you can also better match the flow rate to the patient’s inspiratory drive (I also really like the compact disposable patient circuit). 

2. Demand-Flow - There are currently two demand-flow types of CPAPs on the market: the Emergent PortO2Vent and the Airon MACS CPAP. Both of these high-quality devices provide infinitely variable PEEP, a built-in pressure gauge, and they only flow oxygen during inspiration, for reduced oxygen consumption and easier patient monitoring. 

3. Ventilator with CPAP functionality - These are several great devices on the market, including the LSP AutoVent 4000, CareVent ALS+, Impact’s 754 and new 731, and the Draeger Oxylog 3000. A few can deliver either CPAP or BiPAP at the preference of the physician. Most have advanced respiratory monitoring capabilities well beyond those found on the other types of EMS CPAP devices. And they can all serve at least three different roles: work as a CPAP, provide controlled mandatory ventilation for emergency patients, and or work during patient transports as a ventilator. 

4. Disposable - The Boussignac CPAP device is an oxygen-powered disposable PEEP valve and mask assembly. It provides expiratory pressure support generated by the flow of oxygen from a standard regulated oxygen source. It also provides some oxygen enrichment; however, since PEEP is tied to oxygen flow rate, it cannot deliver low PEEP at high FIO2. The only other drawback is that is does not provide Inspiratory Pressure Support, the other half of what makes CPAP beneficial. Another disposable option is the Smith Oxy-PEEP. This product features a variable FIO2 venturi, non-rebreathing bag, and variable PEEP valve. It can provide low PEEP and high FIO2 simultaneously, but it also does not support inspiration with positive airway pressure. The latest disposable CPAP device worth noting is the new O2ResQ. The O2ResQ is a true disposable CPAP of the fixed Downs Flow type. It’s very simple and easy to use; it uses an innovative plastic expansion chamber with venturi air entrainment port, and offers different threshold resistor style PEEP valves. 

CPAP has really come of age in EMS. Once all we had was the choice between an oxygen mask and an ET tube. In medic school we learned a lot about how to breathe for patients that cannot breathe on their own. For the first time, CPAP gives us a practical tool for helping patients ventilate better before they stop breathing. Over half the EMS agencies that could use CPAP under their state protocols now do. If your agency is not among them, it’s time you took another look.

The new Turkel Safety Needle is a huge leap forward in pre-hospital pneumothorax treatment. I've seen many occasions when a properly placed and secured IV cannula had closed off in the musculature of the chest wall. Keep in mind a regular IV catheter is very soft. It’s designed to ride inside a vein without doing damage, so it has to be. I've also seen needle-decompression catheters arrive in the ED never properly placed in the first place. This new device offers innovative solutions for many of the long-standing problems relieving a pneumothorax in the field.

Its Blunt Safety Cannula, housed within the sharp, beveled hollow needle protects underlying tissue from inadvertent needle penetration. It withdraws into the shaft of the needle during penetration actuating a visual indication of correct placement. It has multiple side holes for easy drainage or aspiration. The depth markings on the catheter help you continuously assess catheter location. The catheter is much stronger and engineered to resist collapsing after placement.

The Safety Color Change Indicator, located in the needle hub

• Provides direct visualization of the safety cannula position as the needle is inserted
• Turns Red as the safety cannula is withdrawn into the shaft of the needle
• Turns Green as the safety cannula extends beyond the needle bevel

What could be simpler? As you push it in it indicates Red and the instant you hit free-air it pops over to Green. It comes in an 8.5 fr. X 3.5”size, packaged sterile and ready for immediate use. It even includes a built-in stopcock for convenient attachment of a one-way air valve.

If being an EMT is one of the 5 worst jobs in America, how can we reasonably expect good young people to enter the profession?

Of 200 Jobs studied, these came out on top -- and at the bottom: EMT ranked #196

If you ask me this report is just plain scary. How can we expect to get bright young new medics on the job? We need to drastically cut the supply of Medics by increasing educational requirements and reducing the number of training programs. Only by cutting off the supply of warm bodies can we hope to increase wages fast. If we don't, soon the only new providers will be those few willing to sacrifice home, family, and future for the brief warm glow of satisfaction. Everyone else with a brain and two nickels to rub together will be in nursing school. Now Monster.com is running a commercial that depicts an EMT with the headline "Are You In The Right Job?" Our profession is becoming the butt of jokes. It breaks my heart to see it happen.

The new LMA Supreme™ is much more suitable for EMS use than any other laryngeal mask airway.  The integrated drain tube is designed to channel fluid and gas safely away from the airway.  Several simple and quick tests help verify accurate positioning. The carefully tested design results in a quick learning curve for easy insertion.  Subtle refinements in the mask make correct placement easy. 

The LMA Supreme™ combines the best features of all previous LMA™ airways in one device.  You can use it anytime you might otherwise use a mask, and as a fast backup to an ET Tube. With its integrated drain tube and verifiable placement; the LMA Supreme™ inspires real confidence managing pre-hospital airway emergencies. I think the LMA Supreme is even faster and easier to insert than the King Airway.

Both the King and Supreme are supraglottic rescue airways. Neither deeply penetrates the esophagus like an EOA, Combitube, or Easytube. The upper part of the Supreme's internal mask provides the function of the upper balloon on the King. The flexible tip of the Supreme rests on top of the esophageal sphincter while the King's small balloon fits just inside the esophagus. Both are single lumen airways and neither can invade the trachea. They also share one critical advantage over their predecessors; they are small enough to fit in most intubation kits. A backup airway back in the truck is no airway at all. Both have a gastric port for rapid decompression of the abdomen. Consequently, I see them as much the same type of device.

I've been very reluctant to embrace rescue airways. It was hammered into my head as a youth that Intubation is the Gold Standard. Therefore if I was having trouble it was because my tools were not good enough or even more likely - because I wasn't. That hard line old-school attitude kept me from seeing the truth. The truth is these things work. 

There is a mounting body of evidence supporting the broader adoption of fast, idiot-resistant airways. They do not appear to allow gastric regurgitation during CPR very often, as I had once feared. In some situations like Tactical EMS they have real advantages. We need to focus on what gets the job done adequately in the most hands. It's time for these new supraglottic airways to become an important part of EMS airway management.

The original QuickTrach has been one of the most successful emergency cricothyrotomy or percutaneous airway access devices on the market. The new Quicktrach II has been substantially refined and improved. It offers the following key advantages:

• Pre--assembled and always ready for immediate use.
• Specially ground needle tip makes prior incision with scalpel unnecessary and reduces the risk of bleeding.
• Stopper and safety clip reduce the risk of posterior tracheal wall injury.
• Neck tape allows a quick and safe fixation.
• Cuff seals trachea and allows efficient ventilation with aspiration protection.
• Anatomically shaped “memory” cannula adjusts to the trachea.

I really liked the original QuickTrach. This new version offers several important improvements on what was already one of the best percutaneous airways. The new connectors are much brighter and intuitive. The new flexible tube tip means easier placement with less risk. Last but certainly not least, the new cuff tube means a secure airway. If heaven forbid I ever have to do this - I want the airway to be exactly where I first put it when I roll in the ER door!

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The new Hudson Neb-U-Mask is a combination device that allows for the concurrent delivery of aerosolized medications and high concentrations of oxygen. The innovative design features a nebulizer connection and MDI adaptor, with a high concentration mask and 750ml oxygen reservoir. The nebulizer connection features a port which maintains a closed system when the neb is not in use. Neb-U-Mask is available in both adult and pediatric versions, and is packaged with a Micro Mist® nebulizer and supply tubing for convenience. The device functions at angles up to 90° and features a swivel connector allowing the system to be very comfortable for the patient. The Neb-U-Mask avoids interrupting therapy to give high-flow oxygen and provides flexibility in medication therapy with both a nebulizer port and MDI adaptor.

The third generation AllMed AVC Helmet features a new double-curved Z87.1 certified visor. The visor is now mounted with improved high-quality helmet hardware from Bell Racing. Our new visor offers improved eye protection with a more compact profile, and better optical clarity. All visors are curved from side to side, but this one is also curved from top to bottom - like a fighter pilot's visor. The new visor is made by Gentex, the same way they make combat flight helmet visors. It provides maximum protection without any optical distortion. Our other latest improvement is the new easy-open steel safety buckle.We revised the design to make it easier to operate. It requires two buttons be pushed for release, so it can't come off accidentally in a violent impact.

The AVC Helmet is available in four different sizes. Most Fire-Rescue style helmets are one size fits all style helmets with a ratcheting headband. They are bulky and cumbersome. Where can they often be found at an MVA? On the roof because they just won't fit into places Paramedics work. Because our helmet is produced in 4 different sizes, it never sticks out more than 1.5” from your head. This permits the mobility required to do EMS work in a confined space, like an ambulance.

The AllMed AVC Helmet is designed to protect the wearer in a mobile medical, motor-vehicle work environment. The DOT standard is endorsed by the Consumer Product Safety Commission for all “Wheeled, Large Motor” vehicle activities*. No other EMS Helmet on the market today is built to protect you wear you work – in a moving motor vehicle. Many actually come with a warning label "Not for Use in a Moving Vehicle".

Our AVC Helmet shell is an exclusive high-pressure composite of ballistic Kevlar and aerospace Carbon Fiber. We use less resin by injecting it under pressure, for a lighter and stronger helmet. Having exactly the right amount of resin versus fiber controls laminate structure and insures optimal performance. Most importantly it provides the best impact resistance at the lightest weight possible. We know a helmet too heavey and cumbersome to work in, can't really offer much protection. Fire Helmet are for Firefighters, the AVC Helmet is purpose-built for the workplace hazards and physical demands of a Paramedic.

A few of the unique features include;

• Exclusive Gel-Coat chromed carbon fiber finish standard, subdued optional 
• Steel quick-release buckle
• Star of Life die cut crown pad, with a Reflective Star of Life front decal.
• Detachable sweatband can be easily removed and cleaned. You also get three different thickness sweatbands for a near custom fit.
• New ANSI Z87.1 visor can be worn over most prescription glasses and features a nose cutout design for optimal eye protection.
• Impervious “wipe-down”, patent-pending expanded polyurethane impact liner makes it easy to keep clean.
• Standard TX-1 LED Helmet Light. The light is safely breakaway mounted and it swivels. It is heat resistant and waterproof, and features 3 super-white LED’s.
• Easy access to the ears, for use of a stethoscope and communications equipment
• “Blackout” Reflective trim for a professional look and 360° enhanced visibility Offered in S, M, L, and XL sizes. Available in Royal Blue, Navy, and Red with other limited custom colors on request.

You can learn more about how & why we came to believe Medics heads need protecting here, here, and here. The image below is our latest finish, a gorgeous semi-opaque blue gel coat over black carbon fiber we will probably call Dark Blue or Navy. It's much more subdued than our standard chromed carbon finished royal blue version.

For BLS Providers and/or Vehicle Use, the version with the 800ml canister has advantages. It will hold a lot more emesis for the continuous suction that is often required when a basic EMT faces a compromised airway. Features common to both versions are a variable vacuum regulator, with an LED display, and an AC/DC field changeable, NiMH battery pack.

Other than the SCCOR Jr. Quickdraw, this is the only powered suction device that really is conveniently portable. If it can fit in your first-in bag it is with you when you need it. Ask yourself, how many times have you had to ask for someone to go back to your rig to get the suction?

I was recently approached by a good customer with a really good question. If disaster can strike on or near highways, and if ANSI vests will soon be required on federal highways, then shouldn't a good Incident Command Vest also meet ANSI high-visibility standards? He was of course, absolutely correct.

The  new AllMed Commander is a dual-purpose Safety Vest. It serves for daily use as a stylish and functional ANSI 107-2004 Class 2 certified Safety Vest.  With a quick title panel change it can be converted into a Disaster or Incident Command Vest in seconds. The Commander sets a whole new standard in safety vests combining a professional uniform appearance with a contemporary style.

Constructed of waterproof 500-denier PU coated nylon - the Commander is built for the demands of professional use. Our rugged ANSI certified fabric is the same type used to make trauma bags. It’s also extremely weather resistant. The Commander pioneers a new more tailored design with the side straps ends tucked neatly away inside the shell. With a foot of adjustment on each side, it can be worn over a heavy coat or a lightweight polo shirt.

It features mesh covered ventilation slots through both the front and back panels for air circulation. The bi-pleated elastic back affords freedom of movement and improved comfort doing demanding work. The full height zipper with rain flap helps keep you protected from bad weather. Another first is the full breathable lining, equal to the outside construction of most other safety vests!

Clear vinyl window pockets on the front and back accept reflective laminated title panels. We offer customized graphic panels for your service name and/or incident command titles. Reflective title panels are flexible, waterproof, and UV resistant. Standard features include tool pockets for scissor, flashlights, or pens, a breast pocket, radio pocket, dual microphone tabs and two roomy inside pockets.

Our 5-pt. breakaway design uses twice the typical amount of hook & loop at the shoulders. We offer it in 5 different sizes - because a vest that fits right doesn’t get snagged in the first place. Our ANSI certified combination reflective trim has a vinyl top layer to help protect the micro bead layer from abrasion. These unique features help make the AllMed Commander the most sophisticated and functional safety vest on the market. The first shipment should arrive in time for the November ANSI deadline. It just finished laboratory testing and is third party certified in full compliance with ANSI 107-2004.

              
We just finished designing a new case to hold at least 7 or 8 Commander Vests with an assortment of reflective title panels